Student Progress Team (Student Conduct)
Incident Report Form

This form should be used by staff or students to report to the Student Progress Team (Student Conduct) any alleged breaches by students of Student Conduct Regulations. 

Please complete this form and send it as an attachment to studentconduct@essex.ac.uk.  If you are unable to submit it by email, you may print this form and hand it in at the Information Desk, Student Services Hub in the Silberrad Student Centre.

If you require any further information, please contact the Student Progress Assistant (Student Conduct), Silberrad Student Centre, email studentconduct@essex.ac.uk, telephone 01206 874370. 

Please note: If you believe you are a victim of harassment or bullying, please read section 6 on page 6 before completing this form.

Please complete the form as fully as possible but include only information known to you personally. Information provided should be as detailed as possible. You may not have all the information requested, in which case, please write ‘unknown’ or ‘unsure’ as appropriate. If handwriting this form please use black ink and BLOCK CAPITALS. 

Today’s date				

   Section 1: Your personal details (person completing this form) 

PRID				
Student Registration Number				
First Name 		Title		
Surname 				
Correspondence Address				
Contact Telephone				
Contact Email (please use University email address if possible)				
Department/ School				
Course				
Year of Study				

Section 2: The incident

a)	Please provide below as many details as possible relating to the student(s) that you believe is/are responsible for the alleged breach of Student Conduct Regulations.

Student 1

PRID				
Student Registration Number				
First Name 		Title		
Surname 				
Department/ School				
Course				

Student 2

PRID				
Student Registration Number				
First Name 		Title		
Surname 				
Department/ School				
Course				

Student 3

PRID				
Student Registration Number				
First Name 		Title		
Surname 				
Department/ School				
Course				

If more than 3 students were involved, please provide the details of the additional students in Section 6 below.

b)	Please state the details of the incident(s) that you wish to report or why you believe a breach of the Student Conduct Regulations has occurred. Please give as much information as possible including times, dates, locations and the names of persons present. If possible, please quote direct speech using the actual words spoken by all parties involved (e.g. X said “Give me all your money” so I replied “I don’t have any”).

Date of Incident		

Details	

	

Section 3: Supporting evidence
Please note that it may be more difficult to investigate or resolve the incident without supporting evidence or witnesses.

A)	Do you have any material evidence (eg photographs, text messages, emails, etc) that may support your complaint?
 YES                		 NO 

If YES, please describe the evidence below and attach copies of the evidence where possible. 

B)	Please provide details of all known witnesses to the incident(s).
Witness 1

PRID				
Student Registration Number				
First Name 		Title		
Surname 				
Department/ School				
Course				

Witness 2

PRID				
Student Registration Number				
First Name 		Title		
Surname 				
Department/ School				
Course				

Witness 3

PRID				
Student Registration Number				
First Name 		Title		
Surname 				
Department/ School				
Course				

If more than 3 witnesses, please provide the details of the additional witnesses in Section 6 below.

Section 4: Has the incident been reported elsewhere?

Have you reported the incident to any other agencies – either connected to or outside the University (e.g. your academic department, the Residence Life, the Police), or has somebody else reported the incident elsewhere?

YES                 		 NO

If YES, please give details below:

Please note that if the matter has been reported to the police and the police are conducting an investigation, a student conduct investigation cannot be commenced until the outcome of the police investigation and any court proceedings that result from it are known. We will liaise with you and with the police to ensure that we begin a conduct investigation at the earliest opportunity.

Section 5: Any additional information not included above (including addition accused students and /or additional witnesses.

Section 6 - Harassment & Bullying

The University considers harassment to be unwanted conduct which has the purpose or effect of violating a person’s dignity or creating an intimidating, hostile, degrading, humiliating, threatening or offensive environment for that person which interferes with their learning, working or social environment. Harassment can be in verbal, written or physical form and can cause stress, anxiety, fear or sickness on the part of the harassed person.
More information about the University’s Zero tolerance approach to harassment and bullying can be found here: https://www.essex.ac.uk/staff/emergencies-security-and-safety/zero-tolerance-of-harassment-and-bullying 
If you would prefer to report an incident of harassment or bullying anonymously or if you wish to speak to an advisor you can do so here: https://reportandsupport.essex.ac.uk/